Mecklenburg Care Transitions Committee Report North Carolina Conference on Aging October 11, 2011

1. Mecklenburg Care Transitions Committee Report North Carolina Conference on Aging October 11, 2011 GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

2. Care Transitions.... …why is it important?

3. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

4. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

5. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

6. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

7. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

8. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

9. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

10. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

11. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

12. GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

13. MECKLENBURG’S APPROACH TO CARE TRANSITIONS GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

14. COMMUNITY CARE TRANSITIONS EVENT MARCH 23, 2011 COVENANT PRESBYTERIAN CHURCH GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

15. Purpose of the Event GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

16. What We Want to Accomplish- Outcomes in Care Transitions Effort Increase percentage of individuals who return home following discharge from hospital when it is their preference to do so Decrease re-admissions to the hospital for the same diagnosis Increase availability of adequate community services and supports GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

17. What Does the Data Say? GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

18. Based on NC State Data Center Projections Mecklenburg County Population GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

19. Mecklenburg Disability Population It is very difficult to determine the population of individuals with disabilities in Mecklenburg County because: • Unlike age, disability is primarily based on self-disclosure • Many disabilities are hidden • People confuse “having a disability” with “getting Disability (SSDI)” GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

20. Mecklenburg Disability Population GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

21. Mecklenburg Disability Population GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days. • People with hearing loss 17% = 156,336 • People who have difficulty seeing (even with aids) 2.5% = 22,990 • People with mental illness 20% = 183,925 • People with intellectual disabilities 1% = 9,196

22. Hospital Studies GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

23. Geographic Variation in Hospital Readmissions 2007 Medicare SAF data GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

24. 30-Day Outcomes Source: NC Hospital Quality Performance Results (2009) Rate = % of Medicare patients readmitted out of the total # of Medicare patients ( number in parenthesis) admitted for these diagnosis between 7/1/2006 and 6/30/2009. Source: www.hospitalcompare.hhs.gov/ GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

25. ANNUAL COST OF CARE FOR AGE, BLIND AND DISABLED MEDICAID PATIENTS ENROLLED IN CAROLINA ACCESS* Source: Community Care Partners of Greater Mecklenburg - Data represents Anson, Union and Mecklenburg Counties Annual Cost of Care For Age, Blind and Disabled Medicaid Patients Enrolled in Carolina Access GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

26. Total Number of Acute Care Visits Per Year For Medicaid Aged, Blind & Disabled Patients Source: Community Care Partners of Greater Mecklenburg – Data represents Anson, Union and Mecklenburg Counties GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

27. Top 8 Leading Causes of Death in Mecklenburg County (2008) • CANCER • HEART DISEASE • STROKE • ALZHEIMER’S DISEASE • CHRONIC OBSTRUCTIVE • PULMONARY DISEASE (COPD) • UNINTENTIONAL INJURY • DIABETES • * source: 2009 State of the County Health Report – Mecklenburg County Health Department GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

28. SMART SOLUTIONSfrom March 23 Event Communication/Education @ collaboration with providers & consumers web based search tool CRC Hospital Disch Partnership 6 mo case managers sharing/Networking Transition Coach/Transitional care Active case mgt partnering w churches Community Patient Resource Improving Continuity of Care 6 steps of transportation 72 of 80 GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

29. TOP THREE SOLUTIONS: GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

30. LEARNINGS SINCE OUR EVENT GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

31. WHAT DO HOSPITALS NEED FROM THE CRC? Challenge of hospitals - Keeping up with program funding - what programs have money? Find creative ways to meet gaps (possibly grants) - transportation & medication Consider ways to meet needs of newly discharged patients - provide community services in a package deal GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

32. WHAT CHARLOTTE-MECKLENBURG HAS IN PLACE FOR CARE TRANSITIONS COMMUNITY CARE PROGRAM OF GREATER MECKLENBURG CRC AND REFERRAL TOOL GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

33. FOCUS GOING FORWARD GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

34. Where Do We Go From Here? GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

35. Where Do We Go From Here? (Continued) GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.

36. PANEL CONTACT INFO Gayla Woody gwoody@centralina.org Centralina Area Agency on Aging Julia Sain juliasain@disability-rights.org Disability Rights & Resources Laura Wasson lauras.wasson@mecklenburgcountync.gov Mecklenburg County Department of Social Services Jane Dawson jane.dawson@carolinashealthcare.org Carolinas HealthCare System Stacy Wright stacywright@novanthealth.org Presbyterian Hospital Denise Bordeman dbordeman@mecklenburgcrc.org Mecklenburg CRC Coordinator

37. "What I do you cannot do; but what you do, I cannot do. The needs are great, and none of us, including me, ever do great things. But we can all do small things, with great love, and together we can do something wonderful."Teresa Calcutta GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with readmissions within 30 days.